Provider Demographics
NPI:1629509021
Name:WIG WAM HAIR
Entity Type:Organization
Organization Name:WIG WAM HAIR
Other - Org Name:WIG WAM WESTBURY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SALES
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:FORGIONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-333-6110
Mailing Address - Street 1:471 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-5106
Mailing Address - Country:US
Mailing Address - Phone:516-333-6110
Mailing Address - Fax:
Practice Address - Street 1:471 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5106
Practice Address - Country:US
Practice Address - Phone:516-333-6110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier